Provider Demographics
NPI:1548711658
Name:CLEMENS, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 NORTHRUP AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4704
Mailing Address - Country:US
Mailing Address - Phone:810-358-3038
Mailing Address - Fax:
Practice Address - Street 1:4234 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8384
Practice Address - Country:US
Practice Address - Phone:616-942-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI1-19-39698103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1548711658Medicaid